Individual
MRS. MALLORY MOODY PUTNAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
2615 FAIRMOUNT AVE, LAKELAND, FL 33803-3159
(863) 661-3887
Mailing address
1324 LAKELAND HILLS BLVD, LAKELAND, FL 33805-4543
(863) 687-1100
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA9106745
FL
Other
Enumeration date
10/29/2012
Last updated
01/30/2017
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